Reducing errors during patient-controlled analgesia therapy through failure mode and effects analysis | JoVE Visualize

Area of Science:

Medical Informatics
Patient Safety
Pharmacology

Background:

Patient-controlled analgesia (PCA) remains a significant source of medication errors in intravenous drug administration, despite advancements in "smart" pump technology.
A Failure Mode and Effects Analysis (FMEA) was conducted in 2003 at a large teaching hospital to assess and improve the PCA process.
Key failure modes identified in patient selection, prescribing, and medication administration processes were targeted for redesign to enhance safety.

Purpose of the Study:

To assess the effectiveness of Failure Mode and Effects Analysis (FMEA) in reducing medication errors associated with patient-controlled analgesia (PCA).
To identify and address specific failure modes within the PCA process to improve patient safety and reduce adverse events.
To evaluate the impact of implemented corrective actions on the incidence of PCA errors.

Main Methods:

A Failure Mode and Effects Analysis (FMEA) was performed on the patient-controlled analgesia (PCA) process.
Hazard scores were used to prioritize failure modes in patient selection, prescribing, and medication administration.
Process redesign was implemented to eliminate identified potential causes of errors.

Main Results:

Prior to FMEA implementation (Jan-May 2003), 11 PCA errors were reported (extrapolated to 26 for the year).
Following corrective actions in 2004, 22 PCA errors were reported.
After implementing an online reporting system in October 2007, PCA errors decreased to 8 (Oct 2007-Sep 2008), a 69% reduction from baseline, with no serious adverse events.

Conclusions:

Failure Mode and Effects Analysis (FMEA) significantly reduced PCA errors, demonstrating its value in improving patient safety.
Despite reductions, misprogramming of drug concentration remains a common PCA error, necessitating further technological solutions like safety software and barcode readers.
FMEA can identify and lead to resolutions for issues beyond its initial scope, such as equipment maintenance systems.